Individual
STACEY RENEE HAVEMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHYSICIAN ASSISTANT
Contact information
Practice address
55 W TIETAN ST, WALLA WALLA, WA 99362-4445
(509) 525-3720
(509) 522-1592
Mailing address
55 W TIETAN ST, WALLA WALLA, WA 99362-4445
(509) 525-3720
(509) 522-1592
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA60389054
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03465758
—
NY
Enumeration date
04/28/2011
Last updated
01/18/2016
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